Yesterday while working in an ultra-high-volume ED (300 patients a day), I witnessed the perfect example of why the prevailing intake model used in the United States is all wrong.
A 21-year old-Hispanic woman presented with a history of two months of progressive chest pain and shortness of breath. The greeter nurse saw a young woman who walked into the ED, designated her nonurgent, and placed her in the waiting room.
More than an hour later, she was brought to a room using slow-motion triage, and I saw a young woman who was grossly cyanotic and plethoric, with enlarged pulsating neck veins sitting up and leaning forward, and with the most amazing clubbed fingers I have ever seen. I observed this from the doorway. You would have recognized this, too.
I'll come back to this to tell you her diagnosis, but let's make the case for putting the physician at the front of the ED encounter instead of the back.
A lot of data support placing physicians at intake. The most compelling argument is that physicians are particularly good at recognizing ill patients. Paramedics correctly predict whether patients will need to be admitted from the ED 62 percent of the time (J Emerg Med 2006;31:1), and other studies report that nurses predict patient disposition with about 78 percent reliability. (Am J Emerg Med 2001;19:10.) On the other hand, there is a growing body of evidence in the literature that demonstrates that physician assessment of outcome and disposition are more highly reliable, with 85 percent to 95 percent accuracy. (Crit Care Med 2006;34:878; Crit Care Med 2004;32:1149; Crit Care Med 1997;25:1801; Aust Health Rev 2007;31:633.) Mind you, the physician's initial assessment is one of the most reliable processes in medicine. You may not know what to call it (the diagnosis), but your “blink” response after a very brief assessment of the patient has very high reliability. You are particularly good at this judgment: Sick or not sick. So why shouldn't the physician encounter be considered sentinel in any intake process?
Dedicating a physician to intake has a number of advantages. Studies have shown that placing a physician in triage decreases the length of stay and walkaways and increases staff satisfaction (Emerg Med J 2004;21:537; Eur J Emerg Med 2006;13:342), and that up to a third of patients can be rapidly discharged using few or no resources. (Emerg Med J 2006;23:262.)
Back to the young woman with the chest pain. At the end of her workup, this woman was found to have Ebstein's anomaly, a type of congenital cyanotic heart disease that can result in thrombus formation and stroke, PSVT, and endocarditis. She was from Central America, and she had never been diagnosed until she came to the ED on this particular day. Her hematocrit was 75, and her oxygen saturations were 75%. She had a big atrial clot and runs of tachycardia. She was about to decompensate on a number of fronts. She was one of the sickest patients in the department, and my nursing colleagues failed to recognize that.
Rather than blame any individual, let's recognize that physicians have more training, knowledge, and experience than our nurse colleagues, and we are better at predicting clinical outcomes than they are. This divide is going to become even more pronounced in the coming decade. The nursing shortage is commonly recognized, but what this means for acute clinical care has not been thoroughly analyzed.
Twenty years ago, it was common to have nurses spend two years in less acute clinical settings (on the floors) before being allowed to work in an ED, OR, or ICU. Twenty years ago, the ED was staffed with the prototypical seasoned and experienced nurses who were competent in clinical skills, but also understood how the ED and the hospital worked, from the politics to the infrastructure. They could often guide the physicians through the complex care pathways for a patient. Now, those nurses work as supervisors in the GI lab, Monday through Friday, no nights and no weekends. Likely they make more money than they did saving lives in the ED. In their place is Ashley, with navel jewelry, who tells you in complete earnestness with wide eyes: “But I don't know how to make a nitroglycerin drip, Dr. Jones!” She is eager, enthusiastic, and utterly inexperienced. (How many gray-haired nurses staff your ED?) Meanwhile the complexity of the acute care needs of ED patients continues to increase. The perfect storm!
Armed with these understandings, I urge you to rethink your front-end processes. Above all, the physicians need to GET OUT FRONT!